Dysphagia in Patients with HNC

4 phases of swallowing

Oral preparatory, oral, pharyngeal, esophageal

Oral preparatory phase

Intake, containment, preparation, and formation of bolus in the oral cavity

Oral phase

Anterior to posterior clearance of bolus through mouth to pharynx

Pharyngeal phase

Clearance of bolus through pharynx into esophagus, includes airway closure and bolus propulsion

Esophageal phase

Clearance of bolus through esophagus to stomach

What phases are most commonly impacted by HNC treatment

Oropharyngeal phases

What CNs are involved in the oropharyngeal phases

V, VII, IX, X, XII

Deglutology

Study of the physiology and pathology of swallowing

Swallowing safety

Keeping bolus out of airway

Swallowing efficiency

How fully and quickly the bolus clears the mouth and pharynx

4 most important factors impacting swallowing in HNC patients

Age, co-morbid conditions, tumor size and location, modality and intensity of treatment

Presbyphagia

Age related deterioration of swallowing function

Swallowing apnea

Reflex to stop breathing when swallowing

How is swallowing effected in older populations

Have longer swallow onset latency, greater respiratory/swallowing incoordination, and longer swallowing apnea

T1-T2 tumors effect on swallowing

Small tumor, patient does not report dysphagia symptoms

T3-T4 tumors effect on swallowing

Large tumors, high grade dysphagia and may need feeding tube

Aspiration

Result of surgical resection or sensorimotor disruption of laryngopharyngeal functions preventing full closing of airway during swallow

Stricture (swallowing)

Abnormal narrowing typically caused by scarring from pharynx or esophageal injury

Three parts of dysphagia evaluation

Physical/physiological function (safety, efficiency, physiology), functional performance (diet, feeding tube), patient precieved function (symptoms, QOL)

FEES

Fiberoptic Endoscopic Evaluation of Swallowing

MBSImP

Modified Barium Swallow Impairment Profile

What are benefits for FEES and MBS compared to each other

FEES: visualization of tumor without radiation exposure

MBS: Can observe peak swallow

Principles of swallowing rehab

Mobilize early and often (use it or lose it), and mass practice of functional activity (high-intensity and frequent swallowing practice)

Two types of progressive therapy methods for building muscle

Device-driven, bolus driven

Device driven therapy

Biofeedback, resistance, or neuromuscular electrical stimulation applied to control intensity of swallowing

Bolus driven therapy

Progressive resistance therapy gradually increasing volume and viscosity

Also called McNeil Dysphagia Therapy Program (MDTP)